Sutureless intestinal anastomosis with the biofragmentable anastomosis ring: experience of 632 anastomoses in a single institute

Gastrointestinal tract anastomoses with the biofragmentable anastomosis ring: is it still a valid technique for bowel anastomosis? Analysis of 203 cases and review of the literature

PURPOSE

Biofragmentable anastomosis ring (BAR) is an alternative to manual and stapled anastomoses performed within the upper and lower gastrointestinal (GI) tract. The aim of this study was to evaluate the effectiveness of BAR utility for bowel anastomoses based on our own material.

METHODS

A retrospective analysis was performed to a total of 203 patients who underwent bowel surgery with the use of BAR anastomosis within upper and lower gastrointestinal tract between 2004 and 2014. Data for the analysis was collected based on medical records, treatment protocols, and the results of histological examinations.

RESULTS

The study group consisted of 86 women and 117 men. The most common underlying pathology was a malignant disease (n = 165). Biofragmentable anastomosis ring (BAR) size 31 was the most commonly used (n = 87). A total of 169 colocolic or colorectal anastomoses and 28 ileocolic and 8 enteroenteric anastomoses were performed. The mortality rate was 0.5 % (n = 1) whereas re-surgery rate within 30 days was 8.4 % (n = 17). Twenty-eight patients developed perioperative complications with surgical site infection as the most common one (n = 11). Eight patients developed specific complications associated with BAR including an anastomotic leak (n = 6) and intestinal obstruction (n = 2). The mean time of hospital stay after surgery was 12.7 days.

CONCLUSIONS

The use of BAR for the GI tract anastomoses is simple and rapid method and it is characterized with an acceptable number of perioperative mortality and complication rates. Based on our experience, we recommend the use of BAR anastomosis in different types of intestinal anastomosis in varying clinical scenarios.

A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery

The reduction of the incidence, detection and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on longterm morbidity and health-care resources has received relatively little attention. Controversy continues regarding the best strategies to reduce the risk. Diagnostic tests lack sensitivity and specificity, resulting in delayed diagnosis and increased morbidity. Intra-operative fluorescence angiography has recently been introduced as a means of real-time assessment of anastomotic perfusion and preliminary evidence suggests that it may reduce the rate of AL. In addition, concepts are emerging about the role of the rectal mucosal microbiome in AL and the possible role of new prophylactic therapies. In January 2016 a meeting of expert colorectal surgeons and pathologists was held in London, UK, to identify the ongoing controversies surrounding AL in colorectal surgery. The outcome of the meeting is presented in the form of research challenges that need to be addressed.

Compression anastomotic ring-locking procedure (CARP) is a safe and effective method for intestinal anastomoses following left-sided colonic resection

BACKGROUND

Compression anastomotic ring-locking procedure (CARP) is a novel procedure for creating colonic anastomoses. The surgical procedure allows perioperative quantification of the compression pressure between the intestinal ends within the anastomosis and postoperative monitoring of the anastomotic integrity. We have recently shown that CARP is a safe and effective method for colonic anastomoses in pigs, and the purpose of the present study was to evaluate CARP for colonic anastomoses in humans.

MATERIALS AND METHODS

This is a prospective study on 25 patients undergoing elective left-sided colonic resection. Time for evacuation of the anastomotic rings, perioperative compression pressure, and adverse effects were recorded. Postoperative blood samples were collected daily, and flexible sigmoidoscopy was performed 8-12 weeks after surgery to examine the anastomoses.

RESULTS

Fourteen out of 25 patients underwent CARP. CARP was not used in 11 patients due to advanced tumor disease (two cases) and size restrictions (nine cases). No case of anastomotic leakage, bowel obstruction, or stenosis formation was observed. No device-related perioperative adverse events were noted. The surgical device evacuated spontaneously in all patients by the natural route after a median of 10 days. Perioperative compression pressure ranged between 85 and 280 mBar (median 130 mBar). Flexible sigmoidoscopy revealed smooth anastomoses without signs of pathological inflammation or stenosis in all cases.

CONCLUSION

Our results indicate that the novel suture-less CARP is a safe and effective method for creating colonic anastomoses. Further studies are warranted in larger patient populations to compare CARP head-on-head with stapled and/or hand-sewn colonic anastomoses.

The compression anastomotic ring-locking procedure: a novel technique for creating a sutureless colonic anastomosis

BACKGROUND/AIM

Compression anastomoses might represent an improvement over traditional hand-sewn or stapled techniques. Herein, we describe a novel concept of sutureless colonic anastomosis named compression anastomotic ring-locking procedure (CARP).

MATERIALS AND METHODS

The surgical device consists of two anastomotic rings and their associated helping tools, facilitating the placement of the rings into the intestinal ends. Furthermore, four catheters are connected to the surgical device, allowing the evaluation of the anastomosis during and after surgery. A total of 31 pigs underwent a low colocolic anastomosis using the anastomotic rings. The compression pressure was measured perioperatively and up to 96 h after surgery. Anastomotic integrity and morphology were analyzed by use of radiology and histology, respectively. A long-term follow-up was conducted in a subgroup of pigs up to 108 days after surgery when the bursting pressure and stricture formation were examined.

RESULTS

All animals recovered uneventfully, and macroscopic examination revealed intact anastomoses without signs of pathological inflammation or adhesions. The perioperative compression pressure was inversely proportional to the gap size between the anastomotic rings. For example, an anastomotic gap of 1.5 mm created a colonic anastomosis with a perioperative compression pressure of 91 mbar, which remained constant for up to 48 h and resulted in a markedly increased compression pressure. Contrast infusion via the catheters effectively visualized the anastomoses, and no leakage was detected within the study. The surgical device was spontaneously evacuated from the intestines within 6 days after surgery. Histology showed collagen bridging of the anastomoses already 72 h after surgery. Long-term follow-up (54-108 days) revealed no stricture formation in the anastomoses, and the bursting pressure ranged from 120 to 235 mbar. The majority of bursts (10/12) occurred distant from the anastomoses.

CONCLUSION

We conclude that the surgical device associated to CARP is safe and efficient for creating colonic anastomoses. Further studies in patients undergoing colorectal surgery are warranted.

"Tie over ring" sutureless compression based gastrointestinal anastomotic method: experimental rat model

INTRODUCTION

Giving the ever-rising trend of pediatric minimally invasive surgery besides early neonatal surgical interventions, intestinal anastomosis turns out to be a time consuming stage due to several anatomical as well as technical difficulties. A perfect bowel anastomosis method should be easy, rapid, safe and reliable in creation of bowel continuity with minimal tissue damage. In this light, sutureless anastomotic methods have been introduced, using compression based anastomosis with biofragmentable rings or powerful magnets. Accordingly, this experimental animal model study has evaluated the result of an easy, rapid intestinal sutureless anastomotic technique via simple tying over an intraluminal ring, in comparison with conventional handsewn bowel anastomosis.

METHODOLOGY

Thirty Wistar-Albino male rats were enrolled and small bowel was transected via a midline laparotomy. A grooved plastic ring was inserted into the ileal lumen and both intestinal cutting ends were fixed over the ring with a simple tie in the first group. On the other hand, enteroenterostomy was performed by the conventional method of handsewn anastomosis in the second group. After 14 days, rats were sacrificed to evaluate for intraperitoneal adhesion and abscess formation in addition to other evidences of anastomotic leakage. Furthermore, the anastomotic site integrity, tensile strength and healing stage were assessed microscopically.

RESULTS

The mean operative time and intraoperative bleeding in the tie over ring group were significantly less than those in the handsewn anastomosis group. Anastomotic stricture was more common in the conventional anastomosis group while the anastomotic tensile strength was significantly higher in the tie over ring group. Histopathological healing parameters and final healing score were almost similar in both groups but mean inflammatory cell infiltration in handsewn anastomosis was significantly higher.

CONCLUSION

"Tie over ring" is a simple method of anastomosis that is feasible, fast, safe and functionally effective for bowel reconstruction in animal models that could be reconsidered in human bowel anastomosis.

Sutureless jejuno-jejunal anastomosis in gastric cancer patients: a comparison with handsewn procedure in a single institute

BACKGROUND

The biofragmentable anastomotic ring has been used to this day for various types of anastomosis in the gastrointestinal tract, but it has not yet achieved widespread acceptance among surgeons. The purpose of this retrospective study is to compare surgical outcomes of sutureless with suture method of Roux-and-Y jejunojejunostomy in patients with gastric cancer.

METHODS

Two groups of patients were obtained based on anastomosis technique (sutureless group versus hand sewn group): perioperative outcomes were recorded for every patient.

RESULTS

The mean time spent to complete a sutureless anastomosis was 11 ± 4 min, whereas the time spent to perform hand sewn anastomosis was 23 ± 7 min. Estimated intraoperative blood loss was 178 ± 32 ml in the sutureless group and 182 ± 23 ml in the suture-method group with no significant differences. No complications were registered related to enteroanastomosis. Intraoperative mortality was none for both groups.

CONCLUSIONS

The Biofragmentable Anastomotic Ring offers a safe and time-saving method for the jejuno-jejunal anastomosis in gastric cancer surgery, and for this purpose the ring has been approved as a standard method in our clinic. Nevertheless currently there are few studies on upper gastrointestinal sutureless anastomoses and this could be the reason for the low uptake of this device.

Intestinal Anastomosis by Use of a Memory-shaped Compression Anastomosis Clip (Hand CAC 30): Early Clinical Experience

Purpose

The safety and the efficacy of the compression anastomosis clip (Hand CAC 30) have been demonstrated by animal studies. This study was designed to evaluate the clinical validity of the Hand CAC 30 in enterocolic side-to-side anastomosis after colonic or enteric resections.

Methods

A non-randomized prospective data collection was performed for patients undergoing a side-to-side anastomosis using the Hand CAC 30. Eligibility criteria for the use of the Hand CAC 30 were for anastomoses between the colon and the ileum or between two small bowels. The primary short-term endpoint was the rate of anastomotic leakage. Other clinical outcomes, including intra- and postoperative complications, length of operation time and hospital stay, and the clip elimination time were recorded.

Results

A total of 63 patients (male, 36) underwent an enteric or right-sided colonic resection followed by a side-to-side anastomosis using the Hand CAC 30. Laparoscopic surgery was performed in 36 patients, in whom one patient who underwent a laparoscopic right hemicolectomy was converted to an open procedure (1/32, 3.1%). One patient with ascending colon cancer showed postoperative anastomotic leakage and died of co-morbid ischemic heart disease. There were no other surgical mortalities. The exact date of expulsion of the clip could not be recorded because most patients were not aware of clip elimination. No patients manifested clinical symptoms of anastomotic stricture.

Conclusion

Short-term evaluation of the Hand CAC 30 anastomosis in patients undergoing enterocolic surgery proved it to be a safe and efficacious alternative to the standard hand-sewn or stapling technique.

Compression anastomoses in colorectal surgery: a review

The main serious risks of anastomotic construction in the colon and rectum include dehiscence and stricture formation. There is a resurgence of interest in sutureless anastomoses formed by compression elements since the introduction of shape memory alloy (SMA) systems, which evoke minimal early inflammatory response whilst maintaining anastomotic integrity. Currently, the most commonly used SMA is the nickel-titanium (NiTi) alloy that is highly biocompatible, returning to its pre-deformed stable (austenite) shape under different mechanical and thermal loads for use in humans. Pre-clinical data for shape memory alloy systems in colorectal anastomoses are limited, but it appears to be safe in porcine and canine models with limited leakage and reduced stricture formation. There does not appear to be any difference in tissue biochemistry of inflammatory markers when compared with conventional stapled techniques, although the few studies available show a markedly reduced early inflammatory response at the anastomotic site with the NiTi device. The majority of the clinical data concerning compression anastomoses are derived from the biofragmentable anastomotic ring device. This device has fallen out of use because of reported leaks, instrumental failure and problems with device expulsion. A novel SMA device, the NiTi anastomotic ring, permits construction of a low rectal anastomosis construction during open or laparoscopic procedures. The preliminary data demonstrate a safety comparable to conventional staple technology. This device also provides the potential of benefit of reduced anastomotic inflammation, because the compression ring results in direct serosa-to-serosa (or alternatively serosa-to-muscularis propria) apposition without the persistence of residual foreign material. This type of construction could lead to a reduced incidence of early anastomotic leakage and/or the development of anastomotic stenosis. Randomized clinical trials employing a NiTi arm for elective, emergency and high-risk colorectal anastomoses are required to determine its indications and clinical profile as well as to assess whether such technology may selectively obviate the need for proximal diversion in low colorectal anastomoses.

Early experience of the compression anastomosis ring (CARTM 27) in left-sided colon resection

AIM: To evaluate clinical validity of the compression anastomosis ring (CAR™ 27) anastomosis in left-sided colonic resection.

METHODS: A non-randomized prospective data collection was performed for patients undergoing an elective left-sided colon resection, followed by an anastomosis using the CAR™ 27 between November 2009 and January 2011. Eligibility criteria of the use of the CAR™ 27 were anastomoses between the colon and at or above the intraperitoneal rectum. The primary short-term clinical endpoint, rate of anastomotic leakage, and other clinical outcomes, including intra- and postoperative complications, length of operation time and hospital stay, and the ring elimination time were evaluated.

RESULTS: A total of 79 patients (male, 43; median age, 64 years) underwent an elective left-sided colon resection, followed by an anastomosis using the CAR™ 27. Colectomy was performed laparoscopically in 70 patients, in whom two patients converted to open procedure (2.9%). There was no surgical mortality. As an intraoperative complication, total disruption of the anastomosis occurred by premature enforced tension on the proximal segment of the anastomosis in one patient. The ring was removed and another new CAR™ 27 anastomosis was constructed. One patient with sigmoid colon cancer showed postoperative anastomotic leakage after 6 d postoperatively and temporary diverting ileostomy was performed. Exact date of expulsion of the ring could not be recorded because most patients were not aware that the ring had been expelled. No patients manifested clinical symptoms of anastomotic stricture.

CONCLUSION: Short-term evaluation of the CAR™ 27 anastomosis in elective left colectomy suggested it to be a safe and efficacious alternative to the standard hand-sewn or stapling technique.

Totally Endoscopic Magnetic Enteral Bypass by External Guided Rendez-Vous Technique

Objective. This study aimed to assess the feasibility of a totally endoscopic enteral bypass using a self-orienting, dual ring, magnetic anastomosis system (MAGNAMOSIS) guided by a magnetic tracking system (3D METRIS). Materials and methods. In an anesthetized pig, 2 endoscopes were advanced, one each into the stomach and the colon. Both endoscopes were equipped with a MAGNAMOSIS ring secured with an endoscopic snare and a 3D METRIS within one working channel. The whole procedure was followed laparoscopically. The tracking system guided tips of endoscopes to a “rendez-vous” location between the colon and stomach. Results. MAGNAMOSIS magnets automatically joined in the correct configuration when guided to within 2 cm of each other. At necropsy, magnetic rings were secure without entrapment of excess bowel or mesentery. Conclusion. An endoscopic enteral bypass with magnetic anastomosis and magnetic tracking device was feasible. More accurate tracking and advanced techniques could enable endoscopic bypasses at multiple sites in the gastrointestinal tract.

Cyanoacrylate for colonic anastomosis; is it safe?

BACKGROUND

This experimental study evaluated the effectiveness and safety of using cyanoacrylate adhesive for sutureless colonic anastomosis and as a protective seal to prevent leakage.

METHODS

Sixty male Sprague-Dawley rats (300 +/- 10 g, 9 weeks old) were divided into three groups: in group I, the anastomosis was sutured in a single layer with 5-0 polypropylene; in group II, the anastomosis was fixed using N-butyl-2-cyanoacrylate (Histoacryl(R)); and in group III, the anastomosis was sutured and then sealed with N-butyl-2-cyanoacrylate. The rats were sacrificed on postoperative day 7. The anastomoses among the three groups were compared by measuring wound infection, anastomotic leakage, anastomotic stricture, adhesion formation, anastomotic bursting pressure, and histological appearance.

RESULTS

No anastomotic leakage was observed in any group. Anastomotic stricture was significantly more extensive in groups II and III (p < 0.001). Bursting pressure was significantly lower in groups II and III (168 +/- 58, 45 +/- 21, and 60 +/- 38 mmHg for groups I to III, respectively, p < 0.001). The severity of inflammatory reactions was significantly greater and collagen deposition was significantly lower in groups II and III (p < 0.05).

CONCLUSIONS

N-butyl-2-cyanoacrylate could be a useful method for sutureless colonic anastomosis based on the absence of anastomotic leakage, but it may impede healing of the colonic anastomosis. In addition, when used to seal sutured colonic anastomoses, cyanoacrylate may have a negative influence on anastomotic healing. The clinical use of N-butyl-2-cyanoacrylate in colonic anastomosis does not appear to be acceptable and safer anastomotic methods or alternative forms of cyanoacrylate should be developed.

Techniques for colorectal anastomosis

Colorectal anastomotic leak remains one of the most feared post-operative complications, particularly after anterior resection of the rectum with, the shift from abdomino-peritoneal resections to total mesorectal excision and primary anastomosis. The literature fails to demonstrate superiority of stapled over hand-sewn techniques in colorectal anastomosis, regardless of the level of anastomosis, although a high stricture rate was noted in the former technique. Thus, improvements in safety aspects of anastomosis and alternatives to hand-sewn and stapled techniques are being sought. Here, we review alternative anastomotic techniques used to fashion bowel anastomosis. Compression anastomosis using compression anastomotic clips, endoluminal compression anastomotic rings, AKA-2, biofragmental anastomotic rings, or Magnamosis all involve the concept of creating a sutureless end-to-end anastomosis by compressing two bowel ends together, leading to a simultaneous necrosis and healing process that joins the two lumens. Staple line reinforcement is a new approach that reduce the drawbacks of staplers used in colorectal practice, i.e. leakage, bleeding, misfiring, and inadequate tissue approximation. Various non-absorbable, semi or fully absorbable materials are now available. Two other techniques can provide alternative anastomotic support to the suture line: a colorectal drain and a polyester stent, which can be utilized in ultra-low rectal excision and can negate the formation of a defunctioning stoma. Doxycycline coated sutures have been used to overcome the post-operative weakness in anastomosis secondary to rapid matrix degradation mediated by matrix metalloproteinase. Another novel technique, the electric welding system, showed promising results in construction of a safe, neat, smooth sutureless bowel anastomosis. Various anastomotic techniques have been shown to be comparable to the standard techniques of suturing and stapling. However, most of these alternatives need to be accepted and optimized for future use.

Experimental study of colonic anastomosis with a degradable stent in a porcine model

BACKGROUND

Intestinal anastomosis is a major technical component of gastrointestinal procedures. We have developed a new procedure of colonic anastomosis with a degradable stent. This article evaluates this procedure.

METHODS

Forty pigs were assigned randomly to a stent group (n = 20) and a control group (n = 20). A colonic anastomosis with a degradable stent was performed in the stent group, and hand-sewn anastomosis was performed in the control group. Pigs of each group were divided evenly into 4 subgroups according to time of death (days 3, 7, and 14, and month 10 postoperatively) to evaluate the healing of anastomosis.

RESULTS

All procedures were completed successfully. The surgical time of the stent group was significantly less than the control group. No complications occurred in either group. Bursting pressure of the stent group was significantly higher than the control group on postoperative days 3 and 7. No significant difference of hydroxyproline content or microvessel density was found between the 2 groups.

CONCLUSIONS

The procedure of colonic anastomosis with a degradable stent is a simple, feasible, and safe procedure in this porcine model.

Compression anastomosis: history and clinical considerations

BACKGROUND

Despite the fact that the concept of compression anastomosis has been investigated for nearly 2 centuries, it has not yet achieved widespread acceptance. The aim of the current report is to review the literature regarding compression anastomoses.

DATA SOURCES

A multi-database search was conducted using PubMed, Ovid, and the Cochrane Databases (all until June 2007), in addition to electronic links to related articles and references of selected articles. The following terms were used for the search in various combinations: anastomosis, anastomoses, sutureless, compression, nickel-titanium; Nitinol; CAC; CAR; AKA-2, Valtrac biofragmentable anastomotic ring, BAR. Language restrictions were not applied.

CONCLUSIONS

The various methods of compression anastomosis have been shown to be at least comparable to the standard techniques of suturing and stapling. The measurement of outcomes, including cost, safety, and efficacy of treatment, indicated that compression anastomosis can save time, is cost-effective, and offers an acceptable cost/benefit ratio compared to both stapled and sutured anastomoses. However, compression anastomosis did not gain worldwide popularity.